Treating Obesity with Indirect Calorimetry

1
Treating Obesity withIndirect Calorimetry

• Evidenced-based Solution for
• Primary Care Practice

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Treating the Overweight and Obese
When we win, I eat. When we lose, I eat. I
also eat when we get rained out
Tommy Lasorda / Manager LA Dodgers
Energy Intake is a major element in determining
whether weight is gained, lost, or maintained.If
your patient is like Tommy Lasorda, your major
challenge is to help that individual manage their
energy balance
Reference Kazaks, A. Obesity Food Intake. In
Bray GA, ed. Office Management of Obesity.
Philadelphia, PA Saunders 2004 91-106.
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Role of Provider
Typically the Primary Care Providers role is to
Manage the disease. However, in treating obesity
a more realistic role for the clinician is
consultant or even coach. The patient must
take the active role in managing their eating
behavior.
Reference Bessesen DH. Applying Stages of
Change theory to Office-based Counseling. In
Bessesen DH. Evaluation and Management of
Obesity. Philadelphia, PA Hanley Belfus, Inc
2002 33-39
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Treating ObesityGuidelines for Primary Care from
NIH / NHLBI
Primary Care Physician Guidelines

• Patient and Physician devise goals and treatment
  strategy for weight loss and risk factor
  control.
• Set a diet that will create a 500-1000 kcal/day
  deficit, to yield a weight loss of 1-2 lbs per
  week
• Maintenance Counseling Dietary therapy, behavior
  therapy, physical activity.
• Assess reasons for failure to lose weight.

Reference National Heart, Lung, and Blood
Institute (NHLBI) National Institutes of
Health. Clinical Guidelines on the
Identification, Evaluation, and Treatment of
Overweight, Obesity in Adults the evidence
report. June 1998
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Treating ObesityGuidelines for Primary Care from
NIH / NHLBI
Primary Care Physician Guidelines
Patient and Physician devise goals and treatment
strategy for weight loss and risk factor control.
Set a diet that will create a 500-1000 kcal/day
deficit, to yield a weight loss of 1-2 lbs per
week
Maintenance Counseling Dietary therapy, behavior
therapy, physical activity.
Assess reasons for failure to lose weight.
Reference National Heart, Lung, and Blood
Institute (NHLBI) National Institutes of
Health. Clinical Guidelines on the
Identification, Evaluation, and Treatment of
Overweight, Obesity in Adults the evidence
report. June 1998
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What is Needed?
When consulting the Overweight or Obese
Patient Make the 5 minutes that is spent with
the patient as efficient and effective as
possible.

• Remove the excuse I have a slow metabolism
• Provide the patient the exact caloric
  prescription that will lead to 1-2
  lbs/week weight loss
• Consult the patient on the need to manage their
  energy balance.
• Motivate the patient to be more active

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Evidence-based Solutions
There is no silver bullet for treating obesity.
The healthcare provider has various tools
available to them to assist their efforts in
treating the patient. It is important that
providers and patients utilize evidence-based
solutions. 1
Dietary Therapy
The healthcare provider should set the patient on
a dietary therapy that will result in a 500-1000
kcal/day deficit that will lead to 1-2 lbs/week
weight loss. A 10 reduction in body weight is
recommended as an initial goal. After reaching
the initial goal, patients should be consulted to
maintain that weight for a period of time.1, 2,
3
Behavior Therapy
The healthcare provider should consult the
patient on the need for reduced caloric intake.
Portion control should be emphasized. Physical
activity and small changes in lifestyle should be
encouraged.1
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Evidence-based Solutions (continued)
Indirect Calorimetry
Indirect calorimetry is the gold standard method
for determining the caloric needs of a patient.
Due to complexity and cost, this has
traditionally been impractical to use outside of
a hospital setting 3,4,5,6,7. Commonly used
predicative normal equations (sex, age, height,
weight) were developed in 1917 5. These are
less effective in obese patients (BMI30) 7.
While it is true that predictive equations can be
used on the population as a whole, individual
errors can be significant 6,7. Knowing the
true energy expenditure is important when
assessing whether the patient is non-compliant or
if the caloric intake prescription is incorrect.
ReeVue Indirect Calorimeter by KORR
In treating obesity, indirect calorimeters can be
used as a tool to take the guesswork out of
determining the patients caloric requirements
3. The ReeVue by Korr simply makes this
practical to do in an outpatient setting.
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Evidence-based Solutions (continued)
Conclusion
This solution described herein is all based on
the well-founded science of Energy Balance. The
goal is to have the patient learn the behavioral
changes needed to manage their weight throughout
their life. Patient compliance is still needed
to obtain results, but the solution allows the
caregiver to give patients the best treatment
available to help them succeed.
References
1 National Heart, Lung, and Blood Institute
(NHLBI) National Institutes of Health. Clinical
Guidelines on the Identification, Evaluation, and
Treatment of Overweight, Obesity in Adults
the Evidence Report. June 1998. 2 Freedman MR,
King J, Kennedy E Popular Diets Scientific
Review. Obesity Research 9(S1)1s-40S2 3
Foster GD, McGuckin BG. Estimating Resting Energy
Expenditure in Obesity. Obes Res. 2001 Dec9
Suppl 5367S-372S 4 Matarese LE. Energy
Dynamics. In Matarese LE Nutritional Support
Practice. A Clinical Guide. Philadelphia, PA
Saunders 2003 77-93 5 Harris JA, Benedict FG.
A Biometric Study of Basal Metabolism in Man.
Washington, DC Carnegie Institute of Washington,
1919. Publication No. 279. 6 McDuffie JR.
Prediction equations for resting energy
expenditure in overweight and normal-weight black
and white children. Am J Clin Nutr. 2004
Aug80(2)365-73. 7 Frankenfield DC, Rowe WA,
Smith JS, Cooney RN. Validation of several
established equations for resting metabolic rate
in obese and non obese people. J Am Diet Assoc.
20031031152-1159
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Why use Indirect Calorimetryin Primary Practice?

• Set the patient on a diet that will create a
  500-1000 kcal/day deficit that will lead to 1-2
  lbs per week weight loss.
• Remove the excuse and the psychological barrier
  by showing the patient the problem is not a SLOW
  METABOLISM
• Teach the patient principles of Energy Balance
  using their own data.
• Assess reasons for failure to lose weight. Is it
  low energy expenditure or is it patient
  non-compliance?

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Now Practical for Primary Care
In the treatment of obesity, assessment of
resting energy expenditure (REE) can provide the
basis for prescribing an individualized energy
intake to attain a desired level of energy
deficit. Indirect calorimetry is the most
frequently used method to measure REE, but the
great expense of equipment precludes its
widespread use. As a result, REE is often
estimated by predictive formulas based on weight,
height, age, and gender. There is a need for
technological advances that will make the
assessment of REE accurate, portable, and
inexpensive
Reference Foster GD, McGuckin BG. Estimating
Resting Energy Expenditure in Obesity. Obes Res.
2001 Dec9 Suppl 5367S-372S
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REEVUE by KORR
The ReeVue is the technological advancement that
makes assessment of resting energy expenditure
(REE)
ACCURATE
PORTABLE
The REEVUE is a Metabolic Cart stripped down
to just the components necessary to perform an
accurate resting energy expenditure (REE)
measurement. Simplicity of use and maintenance
are key.
INEXPENSIVE
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The Procedure
Notes
a. Procedure is very simple and can be performed
by any medical assistant.
b. Procedure and the consult is typically
scheduled as a separate visit.
c. Procedure is CPT Coded and is reimbursed by
Medicare.
1REE is calculated using the Weir equation with
an assumed RQ0.83. See Weir, J.B., New Methods
for Calculating Metabolic Rate with Special
Reference to Protein Metabolism. J. Physiology,
1949 109 pages 1-9 
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The Report
The patients data is presented in a graphical
format that is designed to educate
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Energy Balance Energy In Energy Out
The Report

Energy Out
Energy In
To lose weight, energy intake must be less than
energy expended
A balance scale is used to teach the concept of
energy balance.
Reference Kazaks, A. Obesity Food Intake. In
Bray GA, ed. Office Management of Obesity.
Philadelphia, PA Saunders 2004 91-106.
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The Report
Patients data is presented in graphical format
that creates a forum for education
Energy Output
Energy Intake
Patients Energy Balance
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Provider Consult
The power of the patient provider encounter
should not be underestimated. If the patient is
ready to make changes, the provider is in a key
position to educate and motivate the patient. In
the few minutes you have with the patient you may
need to do the following

• Address Psychological Barriers
• Discuss a Weight loss Strategy
• Set a Caloric Prescription
• Discuss Behavioral Changes
• Send Patient home with Educational Materials

The following slides show how the test results
and the report can assist the caregiver in
providing an effective consult.
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Provider ConsultAddress Psychological Barrier
The calculated predicative normal values are used
for comparison.
Remove the excuse of a slow metabolic rate.
You might say
The test shows that you have a fast metabolic
rate. You can lose weight! Now lets discuss
how to balance what you eat with what your body
burns.
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Provider ConsultDiscuss Weight loss Strategy
The report recommends a range of calories for
effective weight loss
Weight loss Zone (kcal/day)
This is calculated from the measured resting
energy expenditure. Knowing the exact range for
the individual may be the key to their success.
You might say
To lose weight, you need to burn more calories
than you eat. This is the most calories you can
eat and still lose weight!
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Provider ConsultSet a Caloric Prescription
Consult the Patient on the Amount of Daily
Calories
Provider uses the results of the test to
establish a caloric prescription.
You might say
Each day you need to try and target this number
of Calories. You should consider keeping a
record of what you eat each day
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Provider ConsultDiscuss Behavioral Changes
This is not a diet. This is a new way of life!

• Discuss the benefits of being more active.
• Explain that they do not want to increase the
  calories when they Exercise. Let this add to the
  caloric deficit.

Caloric Deficit
You might say
Adding exercise and increasing activity will
help burn more calories and will help the weight
come off faster.
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Provider Consult Send Patient Home with Resources
Educational materials continue the teaching
process
The printout is sent home with patient. The back
of the printout teaches the principles discussed
during the provider consult.
Korr also provides a workbook that the patient
can use to track eating and plan meals. Various
behavioral strategies are taught.
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Troubleshoot the Plateau
Guidelines recommend assessing reasons for
failure to lose weight
Assess Compliance If a metabolic rate test
shows that a patient should be losing weight with
their current caloric prescription, they must not
be compliant.
Assess Caloric Prescription A metabolic rate
test will show if the caloric prescription needs
to change to accommodate changes in the patients
metabolic rate.
You might say
I know you feel you are eating in your weight
loss zone, but according to your RMR test, you
must be eating too much. Lets talk about
keeping a food journal.
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Provider ConsultMaintenance Phase
Energy Balance Like balancing a checkbook, it is
a life skill
Maintenance Zone (kcal/day)
The number of calories needed to maintain weight
is also determined by the REE measurement. The
patient should be counseled to stay below the
upper number of kcal / day
You might say
You have learned how to eat to your metabolism
during the weight loss. Now we just need to
increase your daily calories a little bit for
maintaining your weight.
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Good for the Patient

• Set Correct Caloric Intake
• Address Common Psychological Barriers
• Educate on the Need for Behavioral Changes
• Troubleshoot the Plateau
• Teach a Life-long Skill

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Good for the Practice

• CPT Code Reimbursed by Medicare
• Medicare upper limit 73 nationally
• Fits in Practice Workflow
• Schedule a visit for the procedure
• May schedule a separate provider consult visit
• Increase the efficiency of providers, and the
  effectiveness of patient consultations.
• Provide quality care using evidence-based
  solutions.

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Why do this?

• Co-morbidities of obesity are associated with
  very high healthcare costs. Many disease states
  recommend exercise and dietary changes as the
  first line of defense.
• Obesity is reaching epidemic proportions. A Call
  to Action has been issued. Primary Care
  Providers play a key role.
• Patients are told to look to their healthcare
  provider for help in reaching a healthy weight.
• Apply your medical Best Efforts. Provide the
  best care that is practical and cost-justifiable.

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Is This Right for Your Practice?Things to
Consider

• Workflow Models
• Who does the test, where will we test, when to
  schedule test?
• Financial Justification
• Verify Reimbursement Issues
• Pt Treatment Algorithm
• Which patients to test, when during the patients
  treatment?
• Good Healthcare?
• Does the group believe with the philosophy of
  educating the patient on managing their energy
  balance?
• Is this solution a good method to accomplish this
  goal?

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How to Proceed?

• Practice Evaluation
• Determine if other individuals should be involved
• ie Other Providers, office manager, billing
  clerk
• Determine what issues need to be addressed.
• ie Workflow, Reimbursement, Treatment Algorithm
• Korr has specialists who can assist as needed.

Consider scheduling a conference call with Korr.
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Contacting KORR
Korr Medical Technologies, Inc. 2463 South 3850
West 200 Salt Lake City, Utah 84120
PH [phone]
FX [phone]
Web site WWW.KORR.COM See REEVUE Product Page